Name: Phone:
Address:
City: State: Zip:
How long have you lived at this address? How long in this area?
Anyone living in the home a veteran? _______
Number of people in household: Age 60+ ___ Age 18 - 59? ___Age birth - 17? ____ Total?____
Did you attend our dinner last year? Did we help you last year?
Name: Age Sex Veteran
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
How many adults will be attending the dinner? How many children?
Do you need help with a food basket? Do you need help with toys?
How did you hear about our “Christmas For Needy Children” this year?
_
I understand that if I do not fill out this form completely or I don't print so it can be read I may not
get help. I have enclosed a copy of my picture ID and proof of residence. {Veterans must attach a
copy of their DD214}
_____________________________________ ___________________ _____________________
Signature of person applying for help. Date Email address
| Jonathan Etterling & Michael Orban Memorial CHRISTMAS FOR NEEDY CHILDREN Veterans Helping Veterans & Others, Inc. Registration Form |
| The information on the form below must be mailed to Christmas For Needy Children 502 Short Street West Portsmouth, OH 45663 |
| The form must be filled out completely. You must print and we must be able to read it or you may not receive any help this Christmas. You must send us a copy of your Picture ID and Proof of Residence. {a copy of your utility bill will be fine} IMPORTANT Remember - you must print clearly so we can read your application & it must be filled out completely! |
| Christmas |
